CLM-2026-003641
Mesa Behavioral Health, Behavioral Health. Service 2025-09-30 at telehealth (POS 02). Received 2026-02-26.
Member
Resolved through the identity graph
- Member
- Sarah Wright
- Member ID
- UHC-88130-96
- Date of birth
- 2007-07-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-410237
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0854
- Coverage period
- 2024-01-01 to present
- Deductible
- $31.94 of $3,500.001%
- Out-of-pocket maximum
- $4,330.99 of $14,000.0031%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 7796147859
- Network
- In network
- Rendering NPI
- 4880244510
- Location
- Nashville, TN · TIN 40-4103519
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $287.00 | $177.94 | — | — | DeniedCO29 |
| Totals | $287.00 | $177.94 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-940968
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016114 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-09-30: - (PPO), effective 2024-01-01. | |
| Timely filing | Fail | CO29 | Received 149 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Behavioral Health (7796147859). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Behavioral Health2025-09-30 13:51
Follow-up for generalized anxiety disorder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-26 01:04
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 149 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000632 | 2026-05-12 | Canyon Medical Group | $630.00 | Approved |
| CLM-2026-018570 | 2026-01-15 | Lakeside Reference Lab | $128.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.